Dental treatment can be a stressful experience for many patients as well as dentists. Patient’s dental anxiety has been reported to be a major job stressor for many dentists and they often do not have the time or expertise to deal with this problem (Freeman, 1992; Rouse & Hamilton, 1990). It is estimated that between 50% and 75% of the adults admit some anxiety concerning dental treatment and between 8% and 15% report serious anxiety (Scott & Hirschman, 1982). The dentists usually become aware of the patient anxiety during the treatment procedure. The common symptoms of the dental patient anxiety are heavy breathing, facial grimaces, hand tremors, and perspiration (Geboy, Parisi, Phass, Piet, & Racha, 1983).

Dentists in association with psychologists have long been in search for methods to detect and reduce anxiety in dental patients. Various methods have been proposed to treat anxious dental patients such as relaxation training, systematic desensitization, and cognitive restructuring (Geboy et al., 1983). However, dentists often do not have the time or training to use these complex intervention methods. Some have suggested providing patients’ anxiety profiles to dentists so that they can be pre-informed about the level of patients’ anxiety (Milgrom, Weinstein, Kleinknicht, & Getz, 1985). However, the usefulness of the anxiety profile in the hands of a dentist who is untrained in anxiety management methods is questionable.

The knowledge of patient’s anxiety profile by an untrained dentist may result in a self-fulfilling prophecy (with the patient becoming more anxious). Because previous research has found that when one expects certain behaviors from others, one might treat them in ways that might increase the likelihood that they will behave in the expected fashion (Christensen & Rosenthal, 1982; Kelley, 1950). Snyder and Swann (1978) named this phenomenon as the behavioral/cognitive confirmation effect. Based on this theory, It is possible that if dentists are given the information that their patients are anxious, then they might treat them in ways that create greater patient anxiety. Subsequently, the patient may conform to the dentist’s expectations and become more anxious. This phenomenon occurs when a perceiver selectively interprets and attributes a target person’s actions in ways that are consistent with his or her expectations (Snyder & Swann, 1978).

Further, it has been found that a dentist’s communication and behavior in interacting with his or her patients is directly related to the patient’s satisfaction with the treatment (Corah, O’Shea, & Bissell, 1985; Rouse & Hamilton, 1990; Smith, Weinstein, Milgrom, & Getz, 1984). Thus it may be logical to assume that if high anxiety profiles serve as unfavorable pre-information to dentists and do affect their interactions with patients, then anxious patients might show less satisfaction with treatment.

The purpose of the present study was to examine how patients’ anxiety profiles given as pre-information to dentists would affect (1) dentists’ perception of patients’ anxiety during treatment, (2) patients’ self-perceived anxiety during treatment, and (3) patients’ satisfaction with treatment. The independent variable of pre-information to dentists was varied at three levels: dentists pre-informed that the patients had high level of anxiety (HA Group); dentists pre-informed that patients had low level of anxiety (LA Group), and dentists told nothing of patients’ anxiety levels (Control Group; CG). Based on theory of behavioral/cognitive confirmation effect, HA Group was expected to show greater patient anxiety levels perceived by the dentists during treatment and perceived by patients themselves. Further, based on the findings by Goldman, Cowles, and Florez (1983), and Smith et al. (1984), it was assumed that high anxiety profiles would serve as unfavorable pre-information for dentists and would cause a lack of interaction between dentists and patients, thus resulting in a patient’s lack of satisfaction with treatment in HA Group.

Participants. Ninety adult participants between the ages of 18 and 56 years who were to be treated at a southwestern college of dentistry participated in the present study. Of these 90 patients, 45 reported to have high anxiety and 45 reported to have low anxiety about their dental treatment. These patients were selected from a pool of 177 volunteers scheduled for treatment by dental students at the Endodontics Department at the college of dentistry.

Measurement. Dentists’ perceptions of patients’ anxiety during treatment was measured by a seven point dentist’s rating of patient’s anxiety scale (DPA). Dentists were asked to circle a number on the DPA scale from 1 to 7, 1 indicating that the patient was "very relaxed" and 7 indicating that the patient was "very anxious." Patients’ self-perceived anxiety before and during treatment was measured by the Perceived Stress Index (PSI; Jacobs & Munz, 1968). The PSI scale values ranged from 1.97 (thrilled) to 10.72 (extremely terrified). Patients reporting scores of 7.21 and above were considered having high anxiety and patients with scores of 4.47 and less were considered having low anxiety. Eighty seven patients who scored between 4.48 and 7.20 were eliminated from the sample. The Patient Opinion Poll (POP; Weinstein, Smith, & Bartlett, 1973) was used to assess patients’ overall satisfaction with treatment after the treatment was completed. The POP asked questions varying from patient satisfaction with the dentist’s personal consideration to satisfaction with the professionalism of treatment. The scores on POP ranged from 13 (high satisfaction) to 32 (low satisfaction).

Procedure. One hundred and seventy seven patients who were waiting for treatment in the Endodontics Department at the college of dentistry were asked to complete the informed consent form and PSI. Only those patients whose PSI scores indicated high anxiety and low anxiety were asked to continue participating in the study. Patients chosen from both extremes were randomly assigned to the three groups of dentists (HA, LA, C) and received the treatment for which they came.

Dentists were assigned to the patients based on a rotational procedure used by the college. The dentists in the HA Group were told that their patients had high anxiety levels, the dentists in the LA Group were told that their patients had low anxiety levels, and the C Group was told nothing. In all three groups, dentists were treating patients with both high and low anxiety. After the dental procedure was finished, each dentist was asked to circle a number on the DAP scale and patients were asked to complete the PSI and POP.

There were no significant differences among the three dentist groups regarding the second dependent variable, patients’ self-perceived anxiety during treatment (F_{2, 87} = .76, ns). The mean PSI scores of patients were as follows: HA (M = 4.83; SD = 1.60), LA (M = 5.06; SD = 2.05), and CG (M = 4.72; SD = 1.70).

No significant differences were revealed among the three dentist groups regarding the third dependent variable, patients’ satisfaction with treatment (F_{2, 87} = 2.70, p = .07). The mean POP scores were as follows: HA (M = 14.77; SD = 1.87), LA (M = 16.73; SD = 4.43), and CG (M = 15.90; SD = 3.32). An additional analysis comparing patients with high and low anxiety before treatment was conducted with regard to patient satisfaction. The results showed a significant difference between high anxiety (M = 15.04; SD = 2.17) and low anxiety patients (M = 16.56; SD = 4.23; F_{1, 87} = 4.74, p < .05). The patients who reported to have high anxiety before treatment were significantly more satisfied with treatment than were patients who reported to have low anxiety before treatment.

Significant differences among the three dentist groups were expected with regard to three dependent variables in the present study. The results revealed that dentists who were pre-informed of their patients’ high anxiety levels did evaluate their patients as significantly more anxious during treatment than did dentists who were pre-informed that their patients had low anxiety levels or those who were allowed to draw their own conclusions about their patients’ anxiety levels without being persuaded by the anxiety profiles. Post hoc pairwise comparisons revealed that the dentists were persuaded only by the high anxiety profiles given to them prior to the treatment and the dentist who were told that their patients had low anxiety were not significantly influenced by the pre-information as compared to those dentists who were given no information. These results are consistent with the assumptions by Kelley (1950) and Snyder and Swann (1978) regarding the phenomenon of behavioral/cognitive confirmation effect. In the present study, dentists perceived their patients as anxious because they expected them to be anxious based on their foreknowledge of patients having high anxiety, even though their group consisted of both high and low anxiety patients.

We also expected significant differences among the three dentist groups with regard to patients’ self-perceived anxiety during treatment. We expected that patients would report greater anxiety in HA Group than in both LA and C groups. This was not supported by the findings of the present study. One possible explanation might be that the experimental setting might have created the Hawthorn effect for dentists. It is possible that the dentists became more concerned about their own treatment performance rather than the performance of their patients; thus the patients were not treated in ways to promote the expected behavior.

Goldman et al. (1983) maintained that a lack of interaction between individuals is associated with unfavorable pre-information given to one person about another. Smith et al. (1984) held that the dentist’s interacting behavior with the patient is directly related to the patient’s satisfaction with treatment. Based on these assumptions, we expected LA Group to report greater satisfaction with the treatment than the HA and C groups. However, the results were not significant. An additional analysis was done comparing pre-treatment high anxiety patients to low anxiety patients and the results showed that the patients with pre-treatment high anxiety reported significantly grater satisfaction with the treatment than those who had low anxiety. The high anxiety patients might have experienced greater satisfaction with treatment because they were more grateful that the treatment, which they so feared, was now over. Whereas the less anxious patients reported less satisfaction with treatment because they had not experienced the emotional relief due to the termination of treatment. It is also possible that dentists, through their early treatment interactions with the anxious patients, detected the patients’ anxiety and devoted more care toward those patients, resulting in greater satisfaction. Furthermore, dentists who treated low anxiety patients possibly detected nothing unusual, and carried on with treatment as usual without any special attention and care. This then might have resulted in less patient satisfaction.

Overall, based on the present research, it appears that the main factor contributing to the dental anxiety problem might be the dentist’s perception of the patient’s anxiety levels and not the objective anxiety levels of the patients. Effects of pre-information of patient anxiety levels on dentists before the treatment suggest that the knowledge of anxiety profile of a patient might not be a useful tool in practice of dentistry, because it might negatively affect the dentist-patient relationship, especially when a patient reports a high level of dental anxiety. The finding of reporting greater satisfaction with treatment by the patients who experience higher anxiety levels before the treatment suggests that self-perceived higher anxiety levels of patients before treatment might not be a bad thing in practice of dentistry.

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